Joseph H. Danks

Stability of older adults' preferences for life-sustaining medical treatment.

The use of instructional advance directives assumes that preferences for life-sustaining medical treatment remain stable over time and across changes in life condition. A sample of 332 older adults recorded their preferences for 4 life-sustaining treatments in 9 illness scenarios. These preferences were elicited again 1 and 2 years after the original interview. Overall, preferences for life-sustaining treatment were moderately stable over time, but stability varied significantly across judgments. Preferences were most stable for illness scenarios that were most and least serious and for decisions to refuse treatment. Age, gender, education, and prior completion of an advance directive were all related to preference stability, and evidence indicated that declines in physical or psychological functioning resulted in decreased interest in life-sustaining treatment.

Context Changes Choices: A Prospective Study of the Effects of Hospitalization on Life-Sustaining Treatment Preferences

Objective.Policy and law encouraging individuals to document their wishes for life-sustaining medical treatment in advance of serious illness assumes that these wishes are unaffected by changes in health condition. To test this assumption, the authors examine the life-sustaining treatment preferences of a sample of elderly adults prior to, soon after, and several months after a hospitalization experience. Subjects and Methods. As part of the Advance Directives, Values Assessment, and Communication Enhancement (ADVANCE) project, 401 individuals older than age 65 participated in 3 annual interviews. A subsample of 88 individuals who were hospitalized for greater than 48 hours during the course of the study participated in an additional “recovery” interview conducted soon after their release from the hospital (M = 14 days postdischarge). At each interview, subjects indicated their desire to receive 4 life-sustaining medical treatments in 4 serious illness scenarios.Results. Treatment preferences showed a significant “hospitalization dip,” with subjects reporting less desire to receive life-sustaining treatment at the recovery interview than they did at the annual interview conducted prior to hospitalization, but with desire returning to near prehospitalization levels at the annual interview conducted several months after hospitalization. This dip was more pronounced in preferences for cardiopulmonary resuscitation and artificial nutrition and hydration than in preferences for less invasive treatments. Conclusions. Preferences for life-sustaining treatment are dependent on the context in which they are made, and thus individuals may express different treatment preferences when they are healthy than when they are ill. These results challenge a key psychological assumption underlying the use of instructional advance directives in end-of-life decision making.

Elderly Outpatients Respond Favorably To A Physician-Initiated Advance Directive Discussion

Background: Little is known about the emotional impact of physician-initiated advance directive discussions. Methods: One hundred ambulatory patients aged 65 years and older were randomly assigned to receive either a physician-initiated discussion of advance directive choices or a discussion of health promotion issues. Prediscussion, Immediate postdiscussion, and 1-week postdiscussion measures of positive and negative affect were measured for both groups. Results: Neither discussion topic resulted in adverse emotional or attitudinal responses. Only the advance directive participants showed positive affective and attitudinal responses to the discussion, including an increase in positive affect, an increased sense of physician-patient understanding, and increased thought and discussion about life-support issues in the week following the discussion. For those participants receiving the advance directive discussion, longer physician-patient relationships and higher educational levels significantly predicted a more positive affective response. Lower scores on indices of mental and physical health and a stronger belief that physicians should discuss advance directive issues signiftcantly predicted a more negative affective response to the advance directive discussion. Conclusions: Physicians should anticipate positive emotional responses when they initiate advance directive discussions with their elderly outpatients. Advance directive discussions will be received most positively by patients who enjoy good psychological and physical health and when initiated in the context of an established physician-patient relationship.

GENDER DIFFERENCES IN OLDER ADULTS' PREFERENCES FOR LIFE-SUSTAINING MEDICAL TREATMENTS AND END-OF-LIFE VALUES

In the present study, we examined gender differences in preferences for life sustaining treatments in response to various health state scenarios and the endorsement of end-of-life values in 99 older adults. Men preferred life-sustaining treatments more than women overall, for specific treatments (i.e., CPR, surgery, and artificial feeding), and in response to specific health scenarios (i.e., current health, Alzheimers disease, coma with a slight chance of recovery). In terms of values, women indicated a greater desire for a dignified death than men.In the present study, we examined gender differences in preferences for life sustaining treatments in response to various health state scenarios and the endorsement of end-of-life values in 99 older adults. Men preferred life-sustaining treatments more than women overall, for specific treatments (i.e., CPR, surgery, and artificial feeding), and in response to specific health scenarios (i.e., current health, Alzheimers disease, coma with a slight chance of recovery). In terms of values, women indicated a greater desire for a dignified death than men.

Psychological scaling of adjective orders

Do violations of implicit adjective-ordering rules affect scalings of grammaticalness? Subjects ranked sentences containing one of six different orders of three prenominal adjective classes, using a multiple rank ordering procedure. The scale values were consistent with expectations based upon the assumption that S s integrate a pragmatic communication constraint and a semantic-grammatical rule.

THE STABILITY OF OLDER ADULTS' JUDGMENTS OF FATES BETTER AND WORSE THAN DEATH

Decisions about specific life-sustaining medical treatments have been found to be only moderately stable over time. This study examined whether more general judgments, such as whether a particular health condition is better or worse than death, would exhibit greaterstability. Fifty adults (aged 65 yrs and older) made judgments about the perceived quality of life (QOL) possible in a number of hypothetical states of impaired health and their desire to live or die (LOD) in each state. Judgments were made twice from 5 to 16Decisions about specific life-sustaining medical treatments have been found to be only moderately stable over time. This study examined whether more general judgments, such as whether a particular health condition is better or worse than death, would exhibit greater stability. Fifty adults (aged 65 yrs and older) made judgments about the perceived quality of life (QOL) possible in a number of hypothetical states of impaired health and their desire to live or die (LOD) in each state. Judgments were made twice from 5 to 16 months apart (M = 10.7 mo). Both QOL and LOD judgments demonstrated only moderate stability regardless of the method of analysis used. Judgments about states characterized by severe impairment became more moderate over time with a substantial minority of participants viewing the states as worse than death at the initial interview viewing them as better than death at follow-up. Participants who did not have a living will, did not have children, had a lower perceived QOL at the follow-up interview, and had a longer time between interviews had more unstable judgments. The implications of these findings for the use of instructional advance directives are discussed.

Prenominal Adjective Order and Communication Context.

Will the communication context in which an object is described influence the ordering of prenominal adjectives? While viewing slides of objects in four different contexts, S s heard two descriptions of an object. These descriptions contained two adjectives (size and color) in either a normal or an inverted order with either a stress or a list intonation. If the context necessitated a discrimination based on color, then S s preferred the inverted order of adjectives. If size was the critical attribute, S s strongly preferred the normal order relative to control contexts. These relations were obtained only with stress intonation. The results supported a pragmatic-communication rule which determined prenominal adjective ordering rather than a simple syntactic or semantic rule.

Experimental psycholinguistics : an introduction

Preface 1 Communication systems and the general properties of human language 2 Speech sounds and speech perception 3 Word meanings and the mental dictionary 4 Sentences: syntax, meaning, and comprehension 5 Learning our first language 6 Dialects and schooling 7 Language, thought, and communication References Author index Subject index

Grammaticalness and meaningfulness in the comprehension of sentences

Comprehension of deviant sentences was studied in two experiments. The within sentence variables investigated were grammaticalness (G), meaningfulness (M), word frequency (F), interword association (A), and syntactic frame (Sf). In Experiment I, a principal components analysis of ratings of sentence comprehensibility yielded factors interpretable as ungrammaticalness, nonmeaningfulness, and comprehensibility. In Experiment II, the latencies for Ss to understand the sentences were primarily a function of M and, to a lesser extent, G. The time needed to correct the grammar of the sentences was a function of both G and M, and the time to correct the meaning was a function of M. In both experiments, the effects of F, A, and Sf were either small or insignificant.

Predicting elderly outpatients' life-sustaining treatment preferences over time: The majority rules

Background . This study describes longitudinal changes in the composition and accuracy of modal life-sustaining treatment preferences as predictors of patients’ treatment preferences. Method . Healthy outpatients age 65 and older and their surrogate decision makers recorded preferences for 4 treatments in 9 hypothetical illness scenarios 3 times over a period of 2 years. A statistical prediction model, based on patients’ modal preferences, was created using initial responses and updated 2 years later. Results . When reestimating the model at 2 years, 4 of 27 items in the model created using baseline responses no longer reached the threshold for inclusion, but 5 new items did meet criteria. All modal preference changes reflected a trend toward refusing treatment. Both the original and updated models were more accurate in predicting patients’ preferences than were surrogates making concurrent predictions. Adding covariates (e.g., gender, age, presence of plans for future medical care) did not alter the model’s predictive superiority over surrogates. Conclusions . Models using modal preferences are useful to patients, surrogates, and physicians when trying to accurately discern end-of-life treatment choices, but the models must be updated periodically.